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People with learning disabilities still face inequalities in access to health services. This article, which comes with a handout for a journal club discussion, sums up what nurses can do to reduce these inequalities

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People with learning disabilities still face inequalities in access to health services. This article, which comes with a handout for a journal club discussion, sums up what nurses can do to reduce these inequalities

Abstract

In the last 20 years mindfulness has been incorporated into a number of psychological treatments for mental and physical health conditions. Nurses are now teaching mindfulness to patients in a variety of settings. This article describes the concept of mindfulness, some of the clinical populations that have been treated with this technique, a script for a simple introductory mindfulness exercise and a case study to illustrate its use.

This article has been double-blind peer reviewed

5 key points

By 2020, major depression is predicted to be the second leading cause of disability

There is a growing evidence base for using mindfulness in the treatment of illness

The technique is said to help people with depression or chronic pain, and those living with the experience of hearing voices

Mindfulness is a core component of dialectical behaviour therapy for people with borderline personality disorder

There is a growing interest in the use of mindfulness with older people and their carers

Mindfulness is the skill of being able to bring our attention to what we want to focus on. It involves noticing when our attention wanders, and gently bringing it back to the present moment. It also involves being able to notice - without judgement - our thoughts, emotions, sensations and urges and not getting caught up in them. In this way we can choose when to act on them and when to simply observe them. By using mindfulness we can focus on being effective in the pursuit of short or long-term goals, even in the presence of unhelpful thoughts, emotions or physical sensations.

Evidence base for mindfulness techniques

Whether working with physical health problems or in a mental health setting, mindfulness has been shown to be effective when used with patients with a range of problems (Didonna, 2009). It is a core component of dialectical behaviour therapy (DBT) for people with borderline personality disorder (Linehan, 1993). In DBT, patients use mindfulness skills to gain better control over where they focus their attention, recognise their urges without necessarily acting on them, and increase their awareness of their thoughts, emotions and bodies; in this way they open themselves to experiences rather than avoiding them or acting in impulsive and harmful ways. Lynch (2011) expanded on this approach to incorporate mindfulness into an adaptation of DBT specifically designed for people with current treatment-resistant depression.

Major depression is predicted to be the second leading cause of disability worldwide by 2020 (Murray and Lopez, 1996). Segal et al (2002) developed mindfulness-based cognitive therapy (MBCT) for people who had suffered three or more episodes of depression and were currently in remission. They showed it was effective in reducing relapse for this patient group (Teasdale et al, 2000) by helping patients to recognise their unhelpful thinking patterns without getting caught up in them.

Chadwick (2006) has developed a mindfulness approach to help people living with the experience of hearing voices. By carrying out mindfulness practices, patients learn that they can tune into their life experiences in the moment and “turn down” down their experiences of the voices. This reduces the significance of the voices, enabling them to increase their sense of control and positive beliefs about themselves while increasing their engagement in activities they value.

Kabat-Zinn developed the use of mindfulness with people suffering from chronic pain (Kabat-Zinn et al, 1987). He developed a 10-week mindfulness- based stress reduction (MBSR) programme and showed that people experienced improvement on measures of depression, current pain, negative body image and reduced activity due to pain. Carlson and Garland (2005) developed a programme for people with cancer that is based on Kabat-Zinn’s work. It involves patients practising mindfulness in order to develop a non-judgemental acceptance of situations as they are, and to loosen attachment to unknowable or uncontrollable outcomes.

There is also a growing interest in the use of mindfulness with older people, their family and informal carers and staff involved in their care. McBee (2008) argued that mindfulness practice reminds older people of their inner strength and resources, rather than their losses and disability.

Leading a mindfulness exercise

The first step in leading a mindfulness exercise is to orientate the patient. An introductory metaphor may help, such as the untrained puppy. Kozak (2009) suggested the mind is like an untrained puppy running after squirrels and digging up the flower-beds. We cannot train the puppy by putting it in a box – we have to notice where it has wandered to, and teach it to come back when we call. This is a skill that takes practice.

Most patients can cite examples of when the mind’s actions have been unhelpful, such as: “I just wanted to have lunch with my daughter but kept thinking about my next hospital appointment”, or: “I got invited to a social event but kept thinking I’d make a fool of myself and ended up staying home.”

When choosing the focus for the mindfulness exercise it is easier to start with something external such as an object (Box 1) and to restrict the exercise to five-minutes. Later the patient can move on to exercises that involve observing internal events and doing “body scans”.

After completing the exercise the patient is asked: “What happened when you did this exercise?” This is an opportunity to foster gentle curiosity, and to rephrase the patient’s comments to encourage an “observer position”. The aim is to unhook from content and to notice the process and consequences. (Table 1).

Other types of practice can be given as homework, such as being mindful when making a cup of coffee. Patients can be asked to notice the information coming in through each of the five senses, for example the sound of the water splashing into the kettle, the coldness of the teaspoon, the smell of the coffee as the lid of the jar is removed. The aim is to encourage them to bring their attention to the thoughts and experiences of the current moment, experiencing them without judgement, then passing on to the next experience. Box 2 lists aspects of mindfulness.

Conclusion

Rather than being a cure-all, the skill of mindfulness, namely: “Paying attention in a particular way: on purpose, in the present moment and non-judgementally” (Kabat-Zinn, 1994) is useful to people with a range of difficulties. It allows them to observe their thoughts and emotions as passing mental events, rather than facts that must be believed and acted upon. While there is a growing evidence base for using mindfulness in the treatment of illness, there is also a strong emphasis on the universality of human experience. When teaching mindfulness techniques both the nurse and patient undertake the same experiential exercises and report their feedback to one another.

Mindfulness is taught by those who are themselves regular practitioners of the techniques. This brings a reality and honesty to the practice that cannot be learned through mere reading or visual aids. Nurses working in physical or mental health settings, as well as other healthcare professionals, are encouraged to undertake their own mindfulness practice to enhance their ability to teach these skills.

Maggie Stanton and Christine Dunkley practise and teach mindfulness skills as part of their roles within the NHS and lecture on the subject throughout the UK. www.stantonltd.co.uk and www.grayrock.co.uk

Case study 1. Ovecoming physical and emotional pain

Richard Jones* had lost his wife after a brief illness. He coped with her death by keeping busy, which was exhausting. He also had arthritis, which was painful at times and periodically restricted his mobility. When unable to do tasks he would blame himself, which made him depressed.

Mr Jones’ therapist thought mindfulness practice would help him to stand back from his thoughts and not get caught up in self-blame. She also thought it could help him become more accepting of his physical limitations.

During 12 sessions of mindfulness practice Mr Jones was taught to regularly observe his breath. This helped him to bring himself into the current moment and was a practice he could repeat wherever he was. He used this when his thoughts were running in a negative spiral to bring himself back to the present.

Mr Jones went on to practise mindfulness of his internal environment by noticing his thoughts and sensations and how they would come and go. This helped him to become aware of his emotions, such as sadness, without feeling he needed to block these with constant activity. It also helped him to unhook from his self-critical thoughts. The metaphor of watching his thoughts and emotions like passing carriages on a train rather than getting on to the train was helpful.

The therapist introduced the idea of doing activities mindfully, which Mr Jones practised, for example, when brushing his teeth or making a drink. He found he could use mindfulness in this way when he had pain from arthritis and it helped him to realise the pain was only one input from his senses. He learned to turn down the “volume” of the pain and turn up the impact of other areas of his life.

Finally, his therapist introduced a mindfulness “body scan” and the idea of noticing experiences in a non-judgemental way - letting go of the impulse to categorise experiences as good or bad, right or wrong. She gave examples of how, when we judge something as good, we want to hold on to it and, if we judge it is bad, we want to push it away. Mr Jones learned to accept the painful parts of his body without focusing on them intently or trying to ignore them. He became open to his experiences whatever they were, being willing to let them come and go. He developed an acceptance of the pain in the moment, letting go of the struggle with the pain and was able to focus on doing things he valued irrespective of the pain.

The outcome for Mr Jones was that, over time, while there were occasions he was still sad at the loss of his wife and still had pain from his arthritis, they were transient experiences which were less debilitating and did not prevent him from getting on with his life and doing things he enjoyed.

Mental health nurses at trusts in London are swapping job skills with colleagues in accident and emergency to help both sets of professionals better manage and treat patients with mental health problems.

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